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The SAGE Handbook of Comparative Studies in Education

• Larry E. Suter - University of Michigan
• Emma Smith - University of Warwick
• Brian D. Denman - University of New England
• Description

Educational practices have rapidly changed in the last few decades, especially in how exchanges of information and learning are delivered and processed. Yet, while the field of international comparative studies has grown, there has not been an extensive study on the relationship between educational practices, students, and how practitioners are prepared and trained. This handbook explores international educational practices and behaviours through new research and a review of existing research, with chapters spread across six parts: Part I: The Status of Comparative Education Research Part II: Measurement Methods in Comparative Education Research Part III: Research Practices in Comparative Studies of Education Part IV: Lessons from International Comparisons of Student Behaviors Part V: International Comparisons of Instruction Part VI:  Influence of Large-Scale Assessments on Policy

Larry Suter, Emma Smith, and Brian Denman have done a great service to the field of comparative educational research with this excellent volume.  The breadth of content spanning theory, methodology, and policy is truly amazing, and the outstanding authors that agreed to write chapters for the volume guarantees that this book will become a standard source on comparative educational research in the years to come. 

A handbook on comparative studies in education needs to be international in its sources, contemporary in its outlook, but at the same time acknowledging the very long historical trajectory of such work.   It also needs to be eclectic in the methodologies represented and critical in its approach.   This volume succeeds in meeting all of these requirements and will provide enormous support to scholars around the world for many years to come.

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Understanding Others, Educating Ourselves: Getting More from International Comparative Studies in Education (2003)

Chapter: 1 introduction and rationale, 1 introduction and rationale, introduction.

The increasing scrutiny of earlier studies has revealed their limitations and the consequent need for improvement in the planning, execution, and dissemination of international comparative research…. The lack of an adequate system of education indicators to inform education policy making has become increasingly apparent. Data are not collected regularly, systematically, or with enough coordination either to satisfy natural curiosity about education systems around the world or to answer the questions of researchers and policy makers about changes over time in education in a variety of countries. Trend data are needed on many aspects of education.

A Collaborative Agenda for Improving International Comparative Studies in Education (National Research Council, 1993, hereafter the 1993 Agenda)

By the last half of the 1990s, many concerns described in this excerpt from the 1993 Agenda of the Board on International Comparative Studies in Education had been or were well on the way to being resolved. The proposed solutions, however, produced several new, somewhat overlapping problems. Previously, there was a scarcity of data sufficiently robust to support valid cross-national comparisons; today, a glut of good-quality data overwhelms the field and remains largely unanalyzed, even as new follow-on surveys are launched. Previously, large-scale cross-national education surveys were initiated sporadically, every few years; however, between 1999 and 2003, data collection for at least one and as many as three surveys was scheduled annually.

Previously, U.S. schools faced few mandated tests, and most were willing to participate in the occasional voluntary, internationally oriented tests; today, with increased requirements for mandatory testing, increasing numbers of schools are unwilling to add to their testing burden by participating in voluntary assessments. The infrastructure for conducting large-scale international studies that has developed over the past decade, which plays an important role in ensuring the quality of large-scale international education surveys, has become institutionalized, and the desire to keep this infrastructure engaged has played a role in decisions to support new and more frequent studies. Indeed, there is an increasing concern that international assessments are now conducted more frequently than reforms can produce change in the U.S. education system, which may discourage ongoing, longer term reform efforts.

In addition, the results of large-scale domestic and international surveys are raising a host of questions that often are addressed best by smaller scale studies requiring a wide range of research methods, both qualitative and quantitative. For example, although a full series of more detailed thematic analysis of the data was commissioned before the completion of the first Programme for International Assessment of Student Achievement (PISA) 1 international report, it was of necessity carried out by researchers closely aligned with the study. Few new initiatives have been launched either to cull insight from ongoing nonsurvey-based international studies or to support systematic new ones attuned to independent research agenda.

Despite major investments in a half-dozen large-scale international surveys over the past decade, U.S. public discourse about education remains curiously untouched by international comparisons. Beyond the common knowledge that U.S. students are not first in the world in mathematics and science, educational rhetoric in the United States remains essentially one-dimensional, lacking the sense of rich possibilities that international perspectives can provide. Possible reasons for this deficiency include the general imperviousness of U.S. education policy to domestic or international education research (Lagemann, 2000), and widely shared assumptions that other areas of the world are simply not relevant to the United States. The lack both of interpretive international comparative education studies and of secondary analysis focused on issues of primary concern to the public and policy makers, however, certainly contributes

to the persistence of an inwardly focused approach to education studies in the United States.

The Education Sciences Reform Act of 2002 places strong emphasis on using rigorous scientific methods to study education (U.S. Congress, 2002). This act has reorganized the U.S. Department of Education’s Office of Educational Research and Improvement by creating the Institute of Education Sciences, which includes three centers: the National Center for Education Research, the National Center for Education Evaluation and Regional Assistance, and the National Center for Education Statistics (NCES), one of the main U.S. funders of international comparative education research. This is an important moment to examine the nature of international comparative education research and to reaffirm its critical contribution to a well-rounded program of domestic education research in the United States.

The purpose of this report—which is directed to federal sponsors of international comparative education research, domestic and international researchers, private foundations, and state and district officials who are eager to improve their part of the U.S. education system—is to lay out the rationale for such research; describe its scope, purpose, and potential impact; and make recommendations regarding future directions. Fundamentally, international comparative studies contribute to basic education research by documenting the existence of a much broader array of educational practices and outcomes than is available in the United States alone. International studies, however, can do much more than this. The rest of this chapter explores the current rationale for U.S. participation in international comparative studies and discusses the scope of such studies. Chapter 2 outlines the range of international comparative studies and their relative costs and presents recommendations for moving toward a more balanced research agenda for these studies. Chapter 3 draws on some recent studies to illustrate different ways that international comparative studies have—or, in some cases, have not—made an impact on the U.S. education system. Chapter 4 begins by offering suggestions for continuing to improve one type of study—large-scale, cross-national surveys— with which the board has been mainly involved since its inception, and to address key issues that persist or have emerged with those types of studies since the board’s 1990 report, A Framework and Principles for International Comparative Studies in Education (National Research Council, 1990, hereafter referred to as the 1990 Framework ). It continues by addressing the pressing need for more public access to the findings of all types of international comparative studies and the consequent need for an array of studies addressing a wide range of questions that call for many different research methodologies. Chapter 5 examines the implications of recommendations from earlier chapters for supporting infrastructure, both fi-

nancial and organizational, for future international comparative studies of education. The final chapter provides a summary of the board’s recommendations.

Although many features of international data collection in educational research have changed over the past decade, at least one has not: research that provides comparative information across nations continues to expand understanding of education as a social and economic institution and provide rich sources of ideas about how nations can strengthen teaching and student achievement. Throughout its history, the U.S. education system has benefited immensely from ideas borrowed and adapted from education systems in other countries. These ideas range from methods for early childhood education (France, Germany, and Italy), a model for the structure of higher education (Germany), and goals for mass urban education (England), to the Suzuki method of teaching music (Japan).

Holmes (1985) traces the earliest efforts to observe and learn from foreign education systems to Plato’s reference to Sparta in The Republic . He dates the beginning of comparative education as a systematic study to the early 19th century. He mentions early reservations about the limitations of what is likely to be learned from such study. He cited one educator who claimed that “the practical value of studying other systems of education is that much can be learned about one’s own system of education.” His second claim was that “what goes on outside the schools matters even more than the things inside schools to an understanding of any system of education” (p. 866).

U.S. interest in international education studies has waxed and waned over the decades, but it grew particularly keen after the National Commission on Excellence in Education issued its report, A Nation at Risk (National Commission on Excellence in Education, 1983) . That report made extensive use of findings from then-current national and international comparative studies of student achievement, portraying them in provocative terms. 2 The data cited in that report seized the interest of policy makers, who had little previous knowledge of or interest in comparative international education statistics but who subsequently evolved into strong proponents of comparative research at both state and cross-national lev-

els. 3 Some scholars, however, questioned the use of these particular international studies to judge the U.S. education system, given their imperfect sampling and other technical problems at that time. 4 Nonetheless, by 1990, the president and the governors acknowledged the importance of international perspectives in formulating domestic education policy when they defined national education goals for the nation. The United States was challenged to be first in the world in mathematics and science achievement by the turn of the century, and to ensure that every adult “will be literate and will possess the knowledge and skills necessary to compete in a global economy” (Rothman, 2002).

This focus on comparisons of achievement brought valuable attention to the potential benefits of learning about education in other countries. However, the country rankings that were so widely publicized did little to suggest the breadth of international research.

Cuban (1988) has argued that one remarkable feature of U.S. schools is how alike they are. In contrast, education systems in many other countries encompass a far greater degree of diversity. For example, there tends to be great diversity across nations regarding what citizens expect of their schools, what roles teachers play in society, and what education services governments and private organizations provide. International comparative research in education can help to expand the repertoire of possible practices and policies in several ways.

International education studies help to define what is achievable. How much can students learn and at what age can they learn it? How do different countries mix different amounts of pre-service and in-service professional development for beginning teachers at the early childhood, primary, secondary, and tertiary levels? How do different countries determine the optimal number of hours of schooling at each of these levels? What roles do parents with different levels of education play in governing and supporting schools? Most people would be reluctant to conduct controlled experiments with their children’s educations, but naturally oc-

curring variation in other countries can help develop more confidence in—or courage to consider changing—U.S. policies and practices. Studies such as PISA, for example, demonstrate that high average performance does not have to be associated with the wide disparities in performance found in the United States.

International comparative research can help researchers and policy makers to observe and characterize consequences of different practices and policies for different groups, under different circumstances . Research can examine correlates of various approaches (Holmes, 1985; Postlethwaite, 1999) and explore the reasons for observed differences in student performance, thus enhancing confidence in the generalizability of studies ( 1990 Framework ). It can also contribute to and possibly influence the content and direction of useful debate concerning public issues, such as teenage employment, and the terms of service of teaching, by enhancing the discourse through increasing knowledge about a wider range of alternatives and possible consequences.

International comparative studies often bring to light concepts for understanding education that have been overlooked in the United States, helping U.S. educators to think in terms of new principles and categories. The Second International Mathematics Study helped to popularize the concept of the intended, implemented, and achieved curriculum and facilitated more nuanced discussions and studies about relationships between curriculum and student achievement. A recent book highlighting the expert, “profound” understanding characteristic of Chinese elementary mathematics teachers (Ma, 1999) casts new light on layers of understanding within subject matter knowledge. PISA’s efforts to measure “preparedness for life” have led to new ways to operationalize different types of literacy.

International comparisons of education often lead us to identify and question beliefs and assumptions that are taken for granted . This contribution is sometimes characterized as making the familiar strange and the strange familiar (Kluckhohn, 1944). International comparisons help to raise questions about the universality of particular features of the U.S. education system and offer new insight into current disputes. For example, Japanese teachers can offer cogent reasons why classes of fewer than 20 students are more difficult to teach than larger classes, and why, at the preschool level, teachers often should not discipline a misbehaving student.

Large-scale cross-national surveys have received much attention in the United States in the two decades since the release of A Nation at Risk. Many of the benefits of international comparative education studies, however, are achieved by relatively small-scale, low-cost, more open-ended studies. Such studies, in addition to contributing to our understanding of

the broader range of possibilities in education, are essential precursors to large-scale studies because they help to identify contextual features of school systems that are common to many countries and can be quantitatively measured. Similarly, questions raised by counterintuitive findings of large-scale studies are often best explored by smaller scale, targeted studies.

International comparisons of education systems often produce outcomes that are not part of their original rationale but that nonetheless make valuable contributions to the improvement of U.S. education and international relations.

In an increasingly interdependent world, they provide useful insights into the socioeconomic structure of other countries and cultures. For example, the insights of comparative education scholars who, in relative obscurity, had studied religious schools in Central and South Asia became more valued at the end of 2001, when graduates of those schools attacked the United States.

The challenges posed by international studies can increase the educational research capacity of the United States as well as that of other countries ( 1990 Framework ). For example, the Trends in International Mathematics and Science Study (TIMSS) 5 Videotape Classroom Study helped to raise the technical sophistication of video research methods in the United States and elsewhere. Furthermore, questions of sampling, instrument design, data gathering, and data analysis that had to be addressed in the second and third international mathematics studies yielded results and experience that have been useful in national surveys of achievement.

All these benefits do not flow automatically from every study. Rather, they are more likely to result from systematic investments in a variety of studies, differing in methodology, scope, and purpose, at least some of which try to test and build on earlier findings. Simply observing and measuring apparently effective practices in other countries is not sufficient to bring about desired improvement in U.S. schools. Ideally, promising practices would undergo several rounds of study in the context of their country of origin, and in the United States, in which practitioners and researchers attempt to construct and test hypotheses about the rela-

tionship between the practice and desired outcomes in different settings. More often, informal experiments initiated by practitioners using innovations from other countries attract the attention of researchers post hoc; policy makers call on researchers to investigate promising practices; and, of course, researchers themselves may initiate exploratory studies. Instances of each of these cases are highlighted in boxes throughout the next chapter.

Since 1988, the Board on International Comparative Studies in Education (BICSE) at the (U.S.) National Research Council of the National Academies has engaged in activities designed to increase the rigor and sophistication of international comparative studies in education by encouraging synergies between large and smaller scale international comparative education research, to identify gaps in the existing research base, and to assist in communicating results to policy makers and the public. Under the current grant (1998-2002), funded by the National Science Foundation and the U.S. Department of Education's National Center for Education Statistics, BICSE has sponsored public events and commissioned papers on the effects of the Trends in International Mathematics and Science Study (TIMSS), the power of video technology in international education research, international perspectives on teacher quality, and advances in the methodology of cross-national surveys of education achievement. This report responds to a request from the board's sponsors under the current grant to produce a report that builds on its previous work.

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Article contents

Comparative case study research.

• Lesley Bartlett Lesley Bartlett University of Wisconsin–Madison
•  and  Frances Vavrus Frances Vavrus University of Minnesota
• https://doi.org/10.1093/acrefore/9780190264093.013.343
• Published online: 26 March 2019

Case studies in the field of education often eschew comparison. However, when scholars forego comparison, they are missing an important opportunity to bolster case studies’ theoretical generalizability. Scholars must examine how disparate epistemologies lead to distinct kinds of qualitative research and different notions of comparison. Expanded notions of comparison include not only the usual logic of contrast or juxtaposition but also a logic of tracing, in order to embrace approaches to comparison that are coherent with critical, constructivist, and interpretive qualitative traditions. Finally, comparative case study researchers consider three axes of comparison : the vertical, which pays attention across levels or scales, from the local through the regional, state, federal, and global; the horizontal, which examines how similar phenomena or policies unfold in distinct locations that are socially produced; and the transversal, which compares over time.

• comparative case studies
• case study research
• comparative case study approach
• epistemology

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Theory in Comparative Education

• First Online: 25 March 2021

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• Joseph Zajda 41 &
• Val Rust 42  

Part of the book series: Globalisation, Comparative Education and Policy Research ((GCEP,volume 24))

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Theory is fundamental to the cognitive structure of a field of study (Wells and Picou 1981). The nature and roles of theory have generated a great deal of debate, both within the field of comparative education specifically and within the general academic community. The purpose of this chapter is to examine the place of theory in comparative education, at least among comparative educators who publish in research journals (Rust 2003a, b). The contextual backdrop for the discussion will be globalization (Zajda 2020a). There are important theoretical differences in the field of comparative education, particularly during this period of globalization (Zajda and Rust 2016a, b). In fact, theory itself is a complex issue that requires some historical discussion to frame its many meanings.

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The major challenge to the social science dominated field came from approaches oriented around the notion that societies are in conflict, who claimed the social sciences were based on ideology more than objectivity (Altbach 1991 ) (Epstein 1983 ). In fact, the term “positivism” soon took on an odious reputation among certain scholars. Conflict theorists were soon joined by other theoretical, ideological and disciplinary orientations, including various feminist theories (Kelly and Nihlen 1982 ; Stromquist 1990 ), post-structural theories (Cherryholmes 1988 ), and postmodern theories (Rust 1991 ), which have entered comparative education discourse. Interpreters of the field suggest that challenges have helped shift the field away from its positivistic perspective and have broadened the scope of theoretical orientations considered to be legitimate (e.g., Morrow and Torres 2003 ).

In an essay serving as the basis for a “Colloquy on Comparative Theory” published in the Comparative Education Review (vol. 34, no.3, August 1990) Psacharopoulos challenges “semantics” and argues that what matters in comparative education is the positions taken on “substantive issues”. His four respondents, Don Adams, J. Kenneth Benson, Edmund King, and Rolland G. Paulston, offer several challenges to his point of view, including reminding Psacharopoulos that his own “practical” recommendations were based on human capital theory.

For a debate on Epstein’s characterization, see commentaries in the February 1983 Comparative Education Review .

A complete account of the study is found in (Rust et al. 2000 ).

A small number of theoretical perspectives are not found on Paulston’s map, and researchers used their our own judgment as to their placement on the map.

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Zajda, J., Rust, V. (2021). Theory in Comparative Education. In: Globalisation and Comparative Education. Globalisation, Comparative Education and Policy Research, vol 24. Springer, Dordrecht. https://doi.org/10.1007/978-94-024-2054-8_3

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Victoria Jones received the Fulbright IK award for her doctoral research

Victoria jones received the fulbright iky award for her doctoral research.

This April, Victoria Jones received the Fulbright/IKY PhD Research Award to do field research during the 2024-2025 academic year. Victoria’s dissertation project focuses on how the asylum process for displaced families creates barriers to education for children at the borders of Europe (Greece-Turkey maritime border) and the US (US-Mexico border). Thus, Victoria will conduct fieldwork between September 2024 and March 2025 in Greece and during March and June 2025 at the US-Mexico border.

Victoria, originally from Texas, is a second-year Ph.D. student in the Comparative and International Education Program. Victoria has vast international experience, including having lived abroad for seven years in different countries, including Italy, Colombia, England, and Spain, among others.  In 2017 and 2018, Victoria worked as a language teacher in Italy and in 2019 in Colombia, an experience that led her to co-found a refugee education nonprofit, ELNOR , in 2020. This international pathway and personal experiences have shaped Victoria’s research and professional interests, passionate about access to education for displaced children, education in emergency contexts, and the criminalization of asylum seekers, among many others.

Victoria doing research in Greece during the summer of 2023

As part of her Ph.D. experience, Victoria has worked on different research projects with her advisor, Professor Garnett Russell, including “ The Contexts of Reception and Access to Education: Perspective of Diverse Organizations and Newcomer Families in New York City” or “Education for Transitional Justice, Reconciliation and Peacebuilding: The Case of Colombia”. In her own words, “I am grateful for my work with my advisor in these different projects, which have helped me sharpen my research skills and leverage my prior knowledge towards conducting my dissertation project.”

Victoria Jones presenting her research on asylum seekers and access to education at CIES 2024

Again, we congratulate Victoria for obtaining the Fulbright/IKY PhD Research Award and are excited to see her work developing in the next academic year.

Tags: International Education International Education

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Training nurses in an international emergency medical team using a serious role-playing game: a retrospective comparative analysis

• Hai Hu 1 , 2 , 3   na1 ,
• Xiaoqin Lai 2 , 4 , 5   na1 &
• Longping Yan 6 , 7 , 8  

BMC Medical Education volume  24 , Article number:  432 ( 2024 ) Cite this article

Metrics details

Although game-based applications have been used in disaster medicine education, no serious computer games have been designed specifically for training these nurses in an IEMT setting. To address this need, we developed a serious computer game called the IEMTtraining game. In this game, players assume the roles of IEMT nurses, assess patient injuries in a virtual environment, and provide suitable treatment options.

The design of this study is a retrospective comparative analysis. The research was conducted with 209 nurses in a hospital. The data collection process of this study was conducted at the 2019-2020 academic year. A retrospective comparative analysis was conducted on the pre-, post-, and final test scores of nurses in the IEMT. Additionally, a survey questionnaire was distributed to trainees to gather insights into teaching methods that were subsequently analyzed.

There was a significant difference in the overall test scores between the two groups, with the game group demonstrating superior performance compared to the control group (odds ratio = 1.363, p value = 0.010). The survey results indicated that the game group exhibited higher learning motivation scores and lower cognitive load compared with the lecture group.

Conclusions

The IEMT training game developed by the instructor team is a promising and effective method for training nurses in disaster rescue within IEMTs. The game equips the trainees with the necessary skills and knowledge to respond effectively to emergencies. It is easily comprehended, enhances knowledge retention and motivation to learn, and reduces cognitive load.

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Since the beginning of the twenty-first century, the deployment of international emergency medical teams in disaster-stricken regions has increased world wide [ 1 ]. To enhance the efficiency of these teams, the World Health Organization (WHO) has introduced the International Emergency Medical Team (IEMT) initiative to guarantee their competence. Adequate education and training play a vital role in achieving this objective [ 2 ].

Nurses play a vital role as IEMTs by providing essential medical care and support to populations affected by disasters and emergencies. Training newly joined nurses is an integral part of IEMT training.

Typical training methods include lectures, field-simulation exercises, and tabletop exercises [ 3 , 4 , 5 ]. However, lectures, despite requiring fewer teaching resources, are often perceived as boring and abstract. This may not be the most ideal method for training newly joined nurses in the complexities of international medical responses. However, simulation field exercises can be effective in mastering the knowledge and skills of disaster medicine responsiveness. However, they come with significant costs and requirements, such as extended instructional periods, additional teachers or instructors, and thorough preparation. These high costs make it challenging to organize simulation exercises repeatedly, making them less ideal for training newly joined nurses [ 6 ].

Moreover, classic tabletop exercises that use simple props, such as cards in a classroom setting, have limitations. The rules of these exercises are typically simple, which makes it challenging to simulate complex disaster scenarios. In addition, these exercises cannot replicate real-life situations, making them too abstract for newly joined nurses to fully grasp [ 7 , 8 ].

Recently, game-based learning has gained increasing attention as an interactive teaching method [ 9 , 10 ]. Previous studies have validated the efficacy of game-based mobile applications [ 11 , 12 ]. Serious games that align with curricular objectives have shown potential to facilitate more effective learner-centered educational experiences for trainees [ 13 , 14 ]. Although game-based applications have been used in disaster medicine education, no serious computer games have been designed specifically for training newly joined nurses in an international IEMT setting.

Our team is an internationally certified IEMT organization verified by the WHO, underscoring the importance of providing training for newly joined nurses in international medical responses. To address this need, we organized training courses for them. As part of the training, we incorporated a serious computer game called the IEMTtraining game. In this game, players assume the roles of IEMT nurses, assess patient injuries in a virtual environment, and provide suitable treatment options. This study aims to investigate the effectiveness of the IEMTtraining game. To the best of our knowledge, this is the first serious game specifically designed to train newly joined nurses in an IEMT setting.

The IEMTtraining game was subsequently applied to the training course for newly joined nurses, and this study aimed to investigate its effectiveness. To the best of our knowledge, this is the first serious game specifically designedto train newly joined nurses in an IEMT setting.

Study design

This study was conducted using data from the training records database of participants who had completed the training. The database includes comprehensive demographic information, exam scores, and detailed information from post-training questionnaires for all trainees. We reviewed the training scores and questionnaires of participants who took part in the training from Autumn 2019 to Spring 2020.

The local Institutional Review Committee approved the study and waived the requirement for informed consent due to the study design. The study complied with the international ethical guidelines for human research, such as the Declaration of Helsinki. The accessed data were anonymized.

Participants

A total of 209 newly joined nurses needed to participate in the training. Due to limitations in the size of the training venue, the trainees had to be divided into two groups for the training. All trainees were required to choose a group and register online. The training team provided the schedule and training topic for the two training sessions to all trainees before the training commenced. Each trainee had the opportunity to sign up based on their individual circumstances. Furthermore, the training team set a maximum limit of 110 trainees for each group, considering the dimensions of the training venue. Trainees were assigned on a first-come-first-served basis. In the event that a group reached its capacity, any unregistered trainees would be automatically assigned to another group.

In the fall of 2019, 103 newly joined nurses opted for the lecture training course (lecture group). In this group, instructors solely used the traditional teaching methods of lectures and demonstrations. The remaining 106 newly joined nurses underwent game-based training (game group). In addition to the traditional lectures and demonstrations, the instructor incorporated an IEMTtraining game to enhance the training experience in the game group.

The IEMTTraining game

The IEMTtraining game, a role-playing game, was implemented using the RPG Maker MV Version1.6.1 (Kadokawa Corporation, Tokyo, Tokyo Metropolis, Japan). Players assumed the roles of rescuers in a fictional setting of an earthquake (Part1 of Supplemental Digital Content ).

The storyline revolves around an earthquake scenario, with the main character being an IEMT nurse. Within the game simulation, there were 1000 patients in the scenario. The objective for each player was to treat as many patients as possible to earn higher experience points compared to other players. In addition, within the game scene, multiple nonplayer characters played the role of injured patients. The players navigate the movements of the main character using a computer mouse. Upon encountering injured persons, the player can view their injury information by clicking on them and selecting the triage tags. The player can then select the necessary medical supplies from the kit to provide treatment. Additionally, the player is required to act according to the minimum standards for IEMTs, such as registration in the IEMT coordination cell and reporting of injury information following the minimum data set (MDS) designed by the WHO [ 15 , 16 ]. This portion of the training content imposes uniform requirements for all IEMT members, hence it is necessary for IEMT nurses to learn it. All correct choices result in the accumulation of experience points. Game duration can be set by the instructor and the player with the highest experience points at the end of the game.

Measurement

We have collected the test scores of the trainees in our training database to explore their knowledge mastery. Additionally, we have collected post-training questionnaire data from the trainees to investigate their learning motivation, cognitive load, and technology acceptance.

Pre-test, post-test, and final test

All trainees were tested on three separate occasions: (1) a “pre-test”before the educational intervention, (2) a “post-test”following the intervention, and (3) a “final test”at the end of the term (sixweeks after the intervention). Each test comprised 20 multiple-choice questions (0.5 points per item) assessing the trainees’ mastery of crucial points in their knowledge and decision-making. The higher the score, the better the grade will be.

Questionnaires

The questionnaires used in this study can be found in Part 2 of the Supplemental Digital Content .

The learning motivation questionnaire used in this study was based on the measure developed by Hwang and Chang [ 17 ]. It comprises seven items rated on a six-point scale. The reliability of the questionnaire, as indicated by Cronbach’s alpha, was 0.79.

The cognitive load questionnaire was adapted from the questionnaire developed by Hwang et al [ 18 ]. It consisted of five items for assessing “mental load” and three items for evaluating “mental effort.” The items were rated using a six-point Likert scale. The Cronbach’s alpha values for the two parts of the questionnaire were 0.86 and 0.85, respectively.

The technology acceptance questionnaire, which was only administered to the game group, as it specifically focused on novel teaching techniques and lacked relevance tothe lecture group, was derived from the measurement instrument developed by Chu et al [ 19 ]. It comprised seven items for measuring “perceived ease of use” and six items for assessing “perceived usefulness.” The items were rated on a six-point Likert scale. The Cronbach’s alpha values for the two parts of the questionnaire were 0.94 and 0.95, respectively.

The lecture group received 4 hours of traditional lectures. Additionally, 1 week before the lecture, the trainees were provided with a series of references related to the topic and were required to preview the content before the class. A pre-test was conducted before the lecture to assess the trainees’ prior knowledge, followed by a post-test immediately after the lecture, and a final test 6 weeks after training.

In the game group, the delivery and requirements for references were the same as those in the lecture group. However, the training format differed. The game group received a half-hour lecture introducinggeneral principles, followed by 3 hours of gameplay. The last halfhour was dedicated to summarizing the course and addressing questions or concerns. Similar to the lecture group, the trainees in this group also completed pre-, post-, and final tests. Additionally, a brief survey ofthe teaching methods was conducted at the end of the final test (see Fig.  1 ).

General overview of the teaching procedure. Figure Legend: The diagram shows the teaching and testing processes for the two groups of trainees. Q&A: questions and answers

Data analysis

All data were analyzed using IBM SPSS Statistics (version 20.0;IBM Inc., Armonk, NY, USA). Only the trainees who participated in all three tests were included in the analysis. In total, there were 209 trainees, but 11 individuals (6 from the lecture group and 5 from the game group) were excluded due to incomplete data. Therefore, the data of 198 trainees were ultimately included in the analysis.

In addition, measurement data with a normal distribution were described as mean (standard deviation, SD). In contrast, measurement data with non-normal distributions were expressed as median [first quartile, third quartile]. Furthermore, enumeration data were constructed using composition ratios.

Moreover, a generalized estimating equation (GEE) was employed to compare the groups’ pre-, post-, and final test scores. The Mann–Whitney U test was used to compare the questionnaire scores between the two groups. The statistical significance was set at a level of 0.05.

Among the data included in the analysis, 97 (48.99%) participants were in the lecture group, and 101 (51.01%)were in the game group.

The number of male trainees in the lecture and game groups was 30 (30.93%) and 33 (32.67%), respectively. The mean age of participants in the lecture group was 27.44 ± 4.31 years, whereas that of the game group was 28.05 ± 4.29 years. There were no significant differences in sex or age (Table  1 ). Regarding the test scores, no significant differences were found between the two groups in the pre- and post-tests. However, a significant difference was observed in the final test scores conducted 6 weeks later (Table 1 ).

According to the GEE analysis, the overall scores for the post-test and final test were higher compared to the pre-test scores. Additionally, there was a significant difference in the overall test scores between the two groups, with the game group demonstrating superior performance compared to the control group (odds ratio = 1.363, p value = 0.010). Further details of the GEE results can be found in Part 3 of the supplementary materials .

Table  2 presents the results of the questionnaire ratings for the two groups. The median [first quartile, third quartile] of the learning motivation questionnaire ratings were 4 [3, 4] for the lecture group and 5 [4, 5] for the game group. There were significant differences between the questionnaire ratings of the two groups ( p  < 0.001), indicating that the game group had higher learning motivation for the learning activity.

The median [first quartile, third quartile] of the overall cognitive load ratings were 3 [3, 4] and 4 [4, 5] for the game and lecture groups, respectively. There was a significant difference between the cognitive load ratings of the two groups ( p  < 0.001).

This study further compared two aspects of cognitive load: mental load and mental effort. The median [first quartile, third quartile] for the mental effort dimension were 3 [2, 3] and 4 [4, 5] for the game and lecture groups, respectively (p < 0.001). For mental load, the median [first quartile, third quartile] were 4 [3, 4] and 4 [3, 4] for the game and lecture groups, respectively. There was no significant difference in the mental load ratings between the two groups ( p  = 0.539).

To better understand the trainees’ perceptions of the use of the serious game, this study collected the feedback of the trainees in the game group regarding “perceived usefulness” and “perceived ease of use,” as shown in Table 2 . Most trainees provided positive feedback on the two dimensions of the serious game.

To the best of our knowledge, this IEMT training game is the first serious game intended for newly joined nurses of IEMTs. Therefore, this study presents an initial investigation into the applicability of serious games.

Both lectures and serious games improved post-class test scores to the same level, consistent with previous studies. Krishnan et al. found that an educational game on hepatitis significantly improved knowledge scores [ 20 ]. Additionally, our study showed higher knowledge retention in the game group after 6 weeks, in line with previous studies on serious games. In a study on sexually transmitted diseases, game-based instruction was found to improve knowledge retention for resident physicians compared to traditional teaching methods [ 21 ]. The IEMTtraining game, designed as a role-playing game, is more likely to enhance knowledge retention in newly joined nurses in the long term. Therefore, serious games should be included in the teaching of IEMT training.

This study demonstrated improved learning motivation in the game group, consistent with previous research indicating that game-based learning enhances motivation due to the enjoyable and challenging nature of the games [ 22 , 23 ]. A systematic review by Allan et al. further supports the positive impact of game-based learning tools on the motivation, attitudes, and engagement of healthcare trainees [ 24 ].

As serious games are a novel learning experience for trainees, it is worth investigating the cognitive load they experience. Our study found that serious games effectively reduce trainees’ overall cognitive load, particularly in terms of lower mental effort. Mental effort refers to the cognitive capacity used to handle task demands, reflecting the cognitive load associated with organizing and presenting learning content, as well as guiding student learning strategies [ 25 , 26 ]. This reduction in cognitive load is a significant advantage of serious gaming, as it helps learners better understand and organize their knowledge. However, our study did not find a significant difference in mental load between the two groups. Mental load considers the interaction between task and subject characteristics, based on students’ understanding of tasks and subject characteristics [ 18 ]. This finding is intriguing as it aligns with similar observations in game-based education for elementary and secondary school students [ 27 ], but is the first mention of game-based education in academic papers related to nursing training.

In our survey of the game group participants, we found that their feedback regarding the perceived ease of use and usefulness of the game was overwhelmingly positive. This indicates that the designed game was helpful to learners during the learning process. Moreover, the game’s mechanics were easily understood by the trainees without requiring them to investsignificant time and effort to understand the game rules and controls.

This study had some limitations. First, this retrospective observational study may have been susceptible to sampling bias due to the non-random grouping of trainees. It only reviewed existing data from the training database, and future research should be conducted to validate our findings through prospective studies. Therefore, randomized controlled trials are required. Second, the serious game is currently available only in China. We are currently developing an English version to better align with the training requirements of international IEMT nurses. Third, the development of such serious gamescan be time-consuming. To address this problem, we propose a meta-model to help researchers and instructors select appropriate game development models to implement effective serious games.

An IEMT training game for newly joined nurses is a highly promising training method. Its potential lies in its ability to offer engaging and interactive learning experiences, thereby effectively enhancing the training process. Furthermore, the game improved knowledge retention, increased motivation to learn, and reduced cognitive load. In addition, the game’s mechanics are easily understood by trainees, which further enhances its effectiveness as a training instrument.

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Abbreviations

World Health Organization

International Emergency Medical Team

Minimum Data Set

Generalized estimating eq.

Standard deviation

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Acknowledgements

We would like to thank all the staffs who contribute to the database. We would like to thank Editage ( www.editage.cn ) for English language editing. We also would like to thank Dr. Yong Yang for statistics help. We would like to thank The 10th Sichuan University Higher Education Teaching Reform Research Project (No. SCU10170) and West China School of Medicine (2023-2024) Teaching Reform Research Project (No. HXBK-B2023016) for the support.

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Both Hai Hu and Xiaoqin Lai contributed equally to this work and should be regarded as co-first authors.

Authors and Affiliations

Emergency Management Office of West China Hospital, Sichuan University, The street address: No. 37. Guoxue Road, Chengdu City, Sichuan Province, China

China International Emergency Medical Team (Sichuan), Chengdu City, Sichuan Province, China

Hai Hu & Xiaoqin Lai

Emergency Medical Rescue Base, Sichuan University, Chengdu City, Sichuan Province, China

Day Surgery Center, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China

Xiaoqin Lai

Department of Thoracic Surgery, West China Tianfu Hospital, Sichuan University, Chengdu City, Sichuan Province, China

West China School of Nursing, Sichuan University, Chengdu City, Sichuan Province, China

Longping Yan

West China School of Public Health, Sichuan University, Chengdu, Sichuan, China

West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China

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HH conceived the study, designed the trial, and obtained research funding. XL supervised the conduct of the data collection from the database, and managed the data, including quality control. HH and LY provided statistical advice on study design and analyzed the data. All the authors drafted the manuscript, and contributed substantially to its revision. HH takes responsibility for the paper as a whole.

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Correspondence to Hai Hu .

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Hu, H., Lai, X. & Yan, L. Training nurses in an international emergency medical team using a serious role-playing game: a retrospective comparative analysis. BMC Med Educ 24 , 432 (2024). https://doi.org/10.1186/s12909-024-05442-x

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